Stroke is the 3rd leading cause of death and one of the leading causes of adult long-term disability in the US, with high impact for African Americans. Since 90% of stroke survivors are functionally impaired, improving stroke outcomes is a major public health issue. Agencies such as CMS and the Joint Commission have implemented performance programs including quality indicators (QIs) which would ideally be selected based on impact on stroke-related outcomes, but such evidence is currently scant. The Institute of Medicine has stated that unbiased, reliable information about what works in health care is essential to reducing geographic variation in the use of health care services, and improving quality. We propose to systematically study Qls related to acute ischemic stroke (AIS) care and their associations with the outcomes of cardiovascular disease [CVD] mortality, CVD events, and functional independence. The overall goal is to develop a set of optimal AIS care Qls that maximizes long term outcomes both for patients overall and for specific groups of patients, such as African Americans, and AIS patients with chronic kidney disease (CKD) or diabetes, both more common among African Americans. We aim to 1) examine variations in guideline-concordant process of AIS management, hypothesizing that guideline concordant care will vary by patient, hospital and regional factors, and that adherence to CMS Qls but not other potential Qls will improve over 2003-12; 2) examine associations between processes of AIS management and outcomes, including incremental and relative effectiveness and cost-effectiveness in the >70% with CMS data. hypothesizing that guideline concordant care is associated with lower in-hospital complications and mortality, and that one year later, guideline-concordant inpatient care during the initial AIS hospitalization is associated with lower recurrent stroke, myocardial infarction (Ml), CVD mortality and higher functional independence; 3) examine the association between processes of AIS management and outcomes in AIS patients with CKD or diabetes, hypothesizing that patients with CKD or diabetes will receive less guideline-concordant care than others, and that CKD and diabetes patients receiving guideline-concordant care will have better outcomes than others, but the set of Qls that optimizes quality of life for CKD and diabetes patients will differ compared with those for AIS patients overall. The study will consist of formal chart abstraction of processes of AIS care among 1200 REGARDS subjects, and will use publically available data on hospital characteristics, as well as CMS data.